CPR without rescue breaths [Archive] - BSAC Scuba Diving Forums

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Steve Grrr

22-03-2007, 13:06

JamesW

22-03-2007, 15:32

Hi Steve
This has been on the cards for a few years, I can see when guidelines change next time around (2010) this might happen.
James

Michael Purcell

22-03-2007, 15:47

Seems more about people's unwillingness to put their gob on someone else's mouth more so than a well-researched study clearly indicating that they have confirmed it is superior. I've had a quick look and the Japanese study could likely do with a bit of peer review. (Not that I'm saying it is flawed-heck how would I know) :)

It by no means speaks to divers and actually excludes them as it is strictly speaking of cardiac incidents without prolonged absence of air.

The major first-aid bodies have only endorsed it from the perspective that some CPR is better than no CPR. So I am not certain saying a 2010 change is imminent is a little premature at this point. :)

Ben Panter

22-03-2007, 16:00

If it's published in Lancet then it is peer reviewed.
cheers,
Ben

Michelle Haywood

22-03-2007, 16:28

Would that be the same Lancet that published Andrew Wakefield's MMR and autism paper???? :rolleyes: The quality of peer review can vary enormously from journal to journal. The Lancet is not known for being a hard journal to publish in, usually favoured by medical studies that wouldn't get into the harder science journals because they are not rigorous enough.

However, the real issue with this is that we teach/use CPR in a diving context, and often with oxygen available too. The Japanese study is fine as far as it goes, but IMVHO its unlikely we will see a massive change in what we do now. Doing something is better than nothing, doing something effective is better still. It's a sad fact that most people (even with training) will still fail to respond in a real situation.

Michelle

Adrian Kelland

22-03-2007, 16:39

Andy Wade

22-03-2007, 18:45

Interesting discussion in the Lancet, reported by New Scientist, claiming CPR without rescue breaths gives a better outcome for heart attack victims.

See here (http://www.newscientist.com/article.ns?id=dn11393&feedId=online-news_rss20)

I'm not sure it should affect BSAC teaching though because rescue breaths are still recommended for near drowning.

Steve

We'd better stop calling it CPR then. :)
What a load of b0ll0cks.
I wish they would stop messing around with this.
I'm sure there's more confusion because they seem to change the rate or the technique every couple of years.
IMO the only sensible change they have made in recent years was to stop the first inital thump to the sternum, because people were missing the correct point of impact and breaking ribs.
And to be honest, people were successfully rescusitated using the older methods.
Half of this is to do with the poxy blame culture.

Gareth

22-03-2007, 19:25

Andy Wade

22-03-2007, 19:43

Couldn't agree with you more.

I also think BLS & RB is far more effective in a two or team, if one person is committed to the Chest Compressions & one to the Ventillation, especially when you start to use pocket masks & constant flow O2.
Not only are you in position for your part of the first aid, when you want to swap other individuals in it is far easier.
Having had to do this for real a good few years ago, it worked very well & stopped the team of 5 from becoming exhausted whilst we waited for support.

Gareth

I think this is key, in that most divers are now trained to work as a team in an emergency, so effectiveness is a lot better as we can even afford to have someone do the counting or monitor the effectiveness of compressions or breaths.
That and the O2 of course.
Most people get a big shock on the O2 course when they have to carry out a sustained series of compressions and breaths. This knackers out just about everybody and is a damn good demonstration of what the real thing is going to be like.
Then when they are shown how a team effort can significantly improve effectiveness, they'll never go back to the single person rescue again if they can help it.
There's also the question of being able to encourage each other during the rescue - kind of a 'We're all in this together' sort of thing.

Gareth

22-03-2007, 20:05

There's also the question of being able to encourage each other during the rescue - kind of a 'We're all in this together' sort of thing.

Andy

Couldn't agree with you more on this point, the rescue I was involved in, there was a lot of, mutual encouragement, + reassuring noises for the casualty, like "yep' that's working, he's got colour, he's looking better" etc.

Gareth

Badders (Dave)

23-03-2007, 01:00

I work (as a Volunteer) front line for Staffs Ambulance Service as a community first responder, I do a couple of 12 hour overnight shifts a week.
On a number of occasions I have been stuck waiting for back up doing CPR on my own (you're right it is HARD WORK), thank goodness we now have one of these in our ambulance http://www.lucas-cpr.com/start.php?sid=1 and it does perfect compressions whilst you deal with the breathing, The only down side is it won't fit on large people and they tend to be the ones that need it.

Anyway about the new CPR protocols, it was put to me like this: a stopped hart, even for a few seconds is really bad, where as stopping breathing, even for minutes isn't as bad, so it is more important to keep the heart pumping, also because of the very nature of a cardiac arrest, the oxygenated blood is not moving around the body as quickly and efficiently as it should (even with compressions), so becomes deoxygenated far slower than normal, so requires less oxygen than normal, obviously if possible both circulation and oxygen is best but the hart needs to be pumping at all costs. (the new style CPR takes this into account)
Our protocols (Staffs A.S) for an unwitnessed Cardiac arrest are to do 3 minutes Compressions first. We have been doing this for a while, and using the Lucas device, pioneering stuff really. Have a look t the Cardiac arrest survival statistics for Staffs Ambulance Service compared to all the others, on this linkhttp://www.staffsamb.nhs.uk/ssm2.html (Look for the big red arrow) It's quite impressive, on the face of it the new protocols have helped make quite a difference.
Going a bit off subject, for your info Staffs Ambulance Service is in the middle of being swallowed up by West mids A.S, just out of interest take a look at there performance, they still do it the old way and it is in the balance weather or not Staffs will have to go back to this, quite shocking really.

Badders

Ron Evans

23-03-2007, 01:19

We'd better stop calling it CPR then. :)
What a load of b0ll0cks.
I wish they would stop messing around with this.
I'm sure there's more confusion because they seem to change the rate or the technique every couple of years.
IMO the only sensible change they have made in recent years was to stop the first inital thump to the sternum, because people were missing the correct point of impact and breaking ribs.
And to be honest, people were successfully rescusitated using the older methods.
Half of this is to do with the poxy blame culture.

Andy,

One of the difficulties with medical progress is that it means that what has gone before needs to be changed (or "messed around"). Let's not be Luddites please;)

Ribs break, not because of the initial thump, because of either excessive chest compression, or because the patient has a rigid chest.

None of the changes are to do with "the **** blame culture" : the changes happen because of assessments of success rates with different techniques.

Ron

John Bantin

23-03-2007, 10:28

There are two groups of people to consider during an emergency. The immediate casualty and the emotional casualties (often after the event). It's all very well for medical professionals who deal with emergencies on a day-to-day basis but ordinary people confronted with a situation that is very out of the ordinary often resort to panic. I have seen this first hand. I think that the importance 'battle-hardening' is something that we often under rate today. It does not matter how much you practise on a dummy, the real deal is very different and comes with a long postscript.
So whatever is suggested to keep things as simple as possible must be good.

Mark Hampson

23-03-2007, 12:15

Just to clarify current practice, and as a comment on the Japanese Study the Resus council have just issued a statement which if you read is vey clear.

http://www.resus.org.uk/pages/compCPRs.htm

Mark

Badders (Dave)

23-03-2007, 12:33

Just to clarify current practice, and as a comment on the Japanese Study the Resus council have just issued a statement which if you read is vey clear.
any CPR is better than no CPR.

http://www.resus.org.uk/pages/compCPRs.htm

Mark

The really important thing in this sort of situation is for people to do something and not to freeze because they are worrying about the details.

As divers we are trained and prepared to do something immediately and positively, by the looks of some of the posts on this thread it appears that this has been to good effect.

Badders

William van Niekerk

23-03-2007, 13:08

I read the various comments on Nagao et al‘s paper (as reported in NewScientist) with some interest. Have any of you actually read the paper? I’m afraid that I’m currently stuck in deepest, darkest Africa, and haven’t had a chance to seek out the Lancet in question (don’t ask how I got access to the internet, or why, of all things, I decided to check the BSAC Forums rather than "more important" things like my e-mails!).

Just a few comments from the medical perspective:

1. Michelle, although I agree with much of what you say, I would like to point out that the Lancet is one of the two most respected journals in the medical literature. It is an incredibly difficult journal to publish in. You are correct that it has a much lower citation index or “impact factor” than New Scientist, or Scientific American, or any of the “basic sciences” journals like Cell or Development, but you also have to consider that an article in a scientific journal is aimed at a specific audience. Where you submit it to depends to a large extent on who you want to read it. It would have been inappropriate to submit this article to a “harder science journal” (to use your own words).

2. This brings me to my second point. This article specifically looked at patients who had suffered myocardial infarctions. It is not aimed at the diving fraternity. These are two vastly different populations. Although a diver may conceivably suffer a heart attack as a primary insult, and will no doubt develop myocardial ischaemia and ultimately infarction as a secondary insult in other situations if s/he remains without oxygen for long enough, you are far more likely (as a diver) to be caught up in a resuscitation situation where someone has suffered a respiratory arrest and requires oxygen (via AV, ambu bag, or whatever), rather than (or in addition to) chest compressions. Aside from this, there are also practical considerations - try performing chest compressions on a floating adult casualty in full scuba gear.

3. Furthermore, medicine is not an exact science. Although Nagao’s paper cites impressively large numbers, it is a retrospective study. Retrospective studies do not carry much weight, but it would be ethically questionable, and technically well nigh impossible to design a more robust prospective, double-blind, randomized controlled trial! His findings will have to be very carefully considered before anyone makes fundamental changes to resuscitation protocols based on this paper alone. Even then, recommendations may only be aimed at a specific sub-population of patients.

4. Andy, I have revived two people who had suffered VF arrests with a precordial thump alone (while the defibrillator was still charging up). I’ll continue to use it in the appropriate setting. This brings me back to the last point. BLS protocols are of course based on the available evidence, but are far from written in stone. They are meant to be as simple as possible so that people can remember them and use them correctly (the emphasis is on “use”). If some technique is included which is difficult to use, or rarely indicated, then there is little point (so I sympathise fully with your sentiment - but I have to point out that ribs break because of chest compressions, and not precordial thumps). Furthermore, they are written as protocols so that everyone involved in the arrest situation will sing from the same hymn book. These protocols are by no means a guarantee for success, even if they are followed to the letter, and we’ll have to accept the fact that they will propably continue to be revised (sometimes senselessly in some of our opinions) over the years to come. But then, you knew that already.

So #$%dy well stop worrying about it, commit the current protocols to memory, and concentrate on more worthwhile pursuits, like scuba diving! As a final thought and as inspiration to always have a go, have a look at this recent incident:
http://www.news24.com/News24/AnanziArticle/0,6935,2-7-1442_2085727,00.html.
(Unfortunately, the boy had the misfortune of being admitted to a South African hospital, and died later, presumably of the complications of secondary drowning).

William

Andy Wade

23-03-2007, 19:10

Andy,

One of the difficulties with medical progress is that it means that what has gone before needs to be changed (or "messed around"). Let's not be Luddites please;)

Ribs break, not because of the initial thump, because of either excessive chest compression, or because the patient has a rigid chest.

None of the changes are to do with "the **** blame culture" : the changes happen because of assessments of success rates with different techniques.

Ron

Whoa... None taken.
Well if you say so.
Look, you're a trained professional and can make medical decisions based on vast amounts of knowledge.
However, I (and many many others) are just amateurs, first aiders, and even though I've been teaching and examining lifesaving and first aid on and off for almost 30 years I still consider myself to be an amateur, which I am.
What works in the outside world on a bobbing boat is 'simple and effective', and we have seen the gamut of changes made many times over the years, things like reversed incline boards (yeah, that'll work in an inflatable), changes to technique and compression/breath rates (a particular bugbear of mine) and the removal of things like checking for carotid pulse. We do have to be as practical as possible and some things were best consigned to the bin. I see this but I've often been left wondering over the years if some things were changed for change's sake.
I'm just having a whinge about it. Which is after all what the forum is for.
But I maintain that if I carried out a rescue using EAR and CCCM like we used to do in the olden days back when I were a lad, that I would have just as much chance of making an effective rescue as I would if using todays techniques.
Pulse is not the only option as we all know and not being able to find a carotid pulse wouldn't stop me looking for other signs like general pallor, finger nail beds, mucous membranes and pupil dilation.
Understanding the whole thing is key and learning how to find the pulse helps people to understand why they are doing what they are doing. So I think we should still teach it, even if we don't examine people to find it.

Oh, and the comment I made about people breaking ribs with that first smack on the sternum? Well, that was one of the reasons passed around at the time for it's removal from the first aid rescusitation protocol. It's what I heard anyway. YMMV.
In a rush people can miss the point of impact. Especially amateurs dealing with their unconscious/not breathing best friend on a cold and windy day out in the North Sea whilst battling seasickness.

The 'blame culture' bit was a trite comment designed to create a stir. :p
Sorry about that.
Guilty as charged, sometimes I'm a little minx.
But my heart is very definitely in the right place. Somewhere under my sternum. :D

Ron Evans

23-03-2007, 19:18

Whoa... None taken.
Well if you say so.
Look, you're a trained professional and can make medical decisions based on vast amounts of knowledge.
However, I (and many many others) are just amateurs, first aiders, and even though I've been teaching and examining lifesaving and first aid on and off for almost 30 years I still consider myself to be an amateur, which I am.
What works in the outside world on a bobbing boat is 'simple and effective', and we have seen the gamut of changes made many times over the years, things like reversed incline boards (yeah, that'll work in an inflatable), changes to technique and compression/breath rates (a particular bugbear of mine) and the removal of things like checking for carotid pulse. We do have to be as practical as possible and some things were best consigned to the bin. I see this but I've often been left wondering over the years if some things were changed for change's sake.
I'm just having a whinge about it. Which is after all what the forum is for.
But I maintain that if I carried out a rescue using EAR and CCCM like we used to do in the olden days back when I were a lad, that I would have just as much chance of making an effective rescue as I would if using todays techniques.
Pulse is not the only option as we all know and not being able to find a carotid pulse wouldn't stop me looking for other signs like general pallor, finger nail beds, mucous membranes and pupil dilation.
Understanding the whole thing is key and learning how to find the pulse helps people to understand why they are doing what they are doing. So I think we should still teach it, even if we don't examine people to find it.

Oh, and the comment I made about people breaking ribs with that first smack on the sternum? Well, that was one of the reasons passed around at the time for it's removal from the first aid rescusitation protocol. It's what I heard anyway. YMMV.
In a rush people can miss the point of impact. Especially amateurs dealing with their unconscious/not breathing best friend on a cold and windy day out in the North Sea whilst battling seasickness.

The 'blame culture' bit was a trite comment designed to create a stir. :p
Sorry about that.
Guilty as charged, sometimes I'm a little minx.
But my heart is very definitely in the right place. Somewhere under my sternum. :D

Andy,

I don't mind you having a whinge about the changes - you know far more about diving than I do, so fair's fair!

Can't let the pulse thing go without me having my whinge;) . The reason that pulses are not felt in the resus situation is that studies have shown that the rescuer feels their own pulse, and interprets that as the casualties, and hence does not apply BLS, when the casualty is in dire need of it - and one of these studies was done on hospital medics, who should know better!

If you are demonstrating arterial pulsation as part of explaining normal physiology, great - but not as part of the BLS sessions, to avoid confusion.

Ron

Andy Wade

23-03-2007, 19:32

Andy,

I don't mind you having a whinge about the changes - you know far more about diving than I do, so fair's fair!

Can't let the pulse thing go without me having my whinge;) . The reason that pulses are not felt in the resus situation is that studies have shown that the rescuer feels their own pulse, and interprets that as the casualties, and hence does not apply BLS, when the casualty is in dire need of it - and one of these studies was done on hospital medics, who should know better!

If you are demonstrating arterial pulsation as part of explaining normal physiology, great - but not as part of the BLS sessions, to avoid confusion.

Ron

Agreed, finding the carotid pulse is fraught with problems as it is, much more so when your fingers are cold 'cos you just got out of the water. Which is when an incident is likely to occur, life being what it is.

ISTR something about there being a bit of a 'fact finding trial' or something, and operating theatre staff having a very low success rate finding a carotid pulse. And if they can't find it every time, what chance do we have?
I'm not sure if that was bull or not, but the story was somewhere along those lines at the time.

PeteM

23-03-2007, 21:28

ISTR something about there being a bit of a 'fact finding trial' or something, and operating theatre staff having a very low success rate finding a carotid pulse. And if they can't find it every time, what chance do we have?
I'm not sure if that was bull or not, but the story was somewhere along those lines at the time.

The trial was in a cardio theatre, where they were stopping peoples hearts and pumping with an artificial heart which has no pulse. Medical pro's were asked to checked the pulse for existance, their success rate was almost exactly 50% - or the same as flipping a coin. If they can not get it right in perfect conditions we have no hope, so we switched to the visual check we do now

Andy Wade

23-03-2007, 21:31

The trial was in a cardio theatre, where they were stopping peoples hearts and pumping with an artificial heart which has no pulse. Medical pro's were asked to checked the pulse for existance, their success rate was almost exactly 50% - or the same as flipping a coin. If they can not get it right in perfect conditions we have no hope, so we switched to the visual check we do now

That sounds about right.
Cheers Pete.

I have a coin that comes up heads all the time.... :D